Aortic insufficiency cardiac catheterization

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Varun Kumar, M.B.B.S.; Lakshmi Gopalakrishnan, M.B.B.S.

Overview

Although echocardiography is now the primary imaging modality used to evaluate aortic insufficiency, cardiac catheterization is often performed in patients with aortic insufficiency primarily to assess for the presence of epicardial coronary artery disease prior to surgical aortic valve replacement. Aortography can also be performed to assess the severity of aortic insufficiency. The presence or absence of an aortic dissection can be evaluated. Left ventricular function (hemodynamics), size, and systolic function (ejection fraction) can also be evaluated.

Cardiac Catheterization

Cardiac catheterization is the insertion of a catheter into a chamber or vessel of the heart. This is done for both investigational and interventional purposes. Coronary catheterization is a subset of this technique, involving the catheterization of the coronary arteries.

Aortography Procedure

A 4-6 F pigtail catheter is generally used to perform aortography. The pigtail catheter is placed a few centimeters above the aortic root. For aortic insufficiency quantification, the catheter is placed in the aortic root approximately 2 cm above the aortic valve. The image intensifier is placed in the 45 degree left anterior oblique view with no cranial or caudal angulation. Usually a total of 40 to 50 cc of dye is injected with approximately 20 cc administered every second. The patients should be informed that they can have a warm feeling throughout their body.

Grading Aortic Insufficiency

Grading the severity of aortic insufficiency is based on the amount of opacification of the left ventricle, two complete cardiac cycles after injection compared to that of the aortic root.

• Grade 1

Brief and incomplete ventricular opacification. Clears rapidly.

• Grade 2

Moderate opacification of the ventricle that clears in less that 2 cycles. Never greater than aortic root opacification.

• Grade 3

Opacification of the ventricle equal to aortic root opacification within 2 cycles. Delayed clearing of ventricle over several cycles.

• Grade 4

Opacification of the ventricle almost immediately that is greater than that of the aortic root with delayed clearing of the ventricle.

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Coronary Angiography

As a result of the regurgitant flow into the left ventricle, there is greater than normal flow in the coronary arteries that tends to dilute the contrast. It can be quite difficult to fill the coronary arteries during a standard injection.

Recommendations for management of CAD in valvular heart disease

Coronary angiography (Class I, Level of Evidence C):

❑ Coronary angiography is recommended before valve surgery in patients with severe VHD and any of the following: History of cardiovascular disease Suspected myocardial ischemia Left ventricular systolic dysfunction In men >40 years of age and postmenopausal women One or more cardiovascular risk factors Evaluation of severe mitral regurgitation

Coronary CT angiography (Class I, Level of Evidence C):

❑ Coronary CT angiography is recommended as an alternative to coronary angiography before valve surgery in patients with severe VHD and low probability of CAD

CABG:(Class I, Level of Evidence C) :

❑ CABG is considered in patients undergone aortic/mitral/tricuspid valve surgery and coronary artery diameter stenosis ≥ 70%

CABG : (Class IIa, Level of Evidence C)

❑ CABG is recommended in patients undergone aortic/mitral/tricuspid valve surgery and coronary artery diameter stenosis ≥ 50-70%

PCI : (Class IIa, Level of Evidence C)

❑ PCI is recommended in patients undergoing TAVI and coronary artery diameter stenosis > 70% in proximal segments ❑ PCI is recommended in patients undergoing transcatheter mitral valve intervention and coronary artery diameter stenosis > 70% in proximal segments

Abbreviations: CAD: Coronary artery disease; CABG: Coronary artery bypass grafting; PCI: Percutaneous coronary intervention; TAVI:Transcatheter aortic valve implantation; VHD:Valvular heart disease

The above table adopted from 2021 ESC Guideline

2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

Only when a diagnosis cannot be made with noninvasive imaging or when an acute coronary syndrome is a differential diagnosis should an angiography be explored.

2008 Focused Update Incorporated into the 2006 ACC/AHA Guidelines for the Management of Patients with Valvular Heart Disease (DO NOT EDIT)

Cardiac Catheterization Indications (DO NOT EDIT)

Class I

"1. Cardiac catheterization with aortic root angiography and measurement of LV pressure is indicated for assessment of severity of regurgitation, LV function, or aortic root size when noninvasive tests are inconclusive or discordant with clinical findings in patients with AR. (Level of Evidence: B)"

"2. Coronary angiography is indicated before AVR in patients at risk for CAD. (Level of Evidence: C)"

Class III

"1. Cardiac catheterization with aortic root angiography and measurement of LV pressure is not indicated for assessment of LV function, aortic root size, or severity of regurgitation before AVR when noninvasive tests are adequate and concordant with clinical findings and coronary angiography is not needed. (Level of Evidence: C)"

"2. Cardiac catheterization with aortic root angiography and measurement of LV pressure is not indicated for assessment of LV function and severity of regurgitation in asymptomatic patients when noninvasive tests are adequate. (Level of Evidence: C)"

Sources

• 2008 focused update incorporated into the 2006 ACC/AHA guidelines for the management of patients with valvular heart disease